If any member of your household receives benefits from the Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, please follow these instructions:A household member is any child or adult living with you.

Part A: Enter the total number of individuals living in your household, including allchildren in the space provided.Part B: List the case number for any household member (including adults) receiving FAP,FIP, or FDPIR benefitsPart C: List the First and Last name, grade, school that the child is attending, and any special circumstances (H ifhomeless, M if Migrant, R if Runaway or F if a Foster Child, or not applicable)Part D: Skip this partPart E: Enter your name, information, and submit form.

If your household does NOT receive benefits from FAP, FIP, or FDPIR, please follow these instructions:

Part A: List the total number of individuals living in your household, including all children.Part B: Skip this part.Part C: List the First and Last name, grade, school that the child is attending, and any special circumstances (H ifhomeless, M if Migrant, R if Runaway or F if a Foster Child, or not applicable).Part D: Enter all gross income for each type of income that applies. If you have no incomefor any 1 or more of the categories, enter "0"Part E: Enter your name, information, and submit form.

Household Survey

To determine eligibility for various additional state and federal program benefits that your school may qualify for, please complete this report. These sections must be completed by the head of household or designee.

PART A. SIZE OF FAMILY
Enter the total number of individuals living in your household, including all adults and children:

PART B. CURRENT BENEFITS - Complete if applicable

If any member of your household receives Food Assistance Program (FAP), Family Independence Program (FIP), or FDPIR, provide the name and case number for the person who receives benefits. Bridge Card Numbers and Medicaid Numbers are NOT ACCEPTABLE case numbers.

Name:

Case Number:

PART C. STUDENT INFORMATION– Complete for each student Pre-K through 12th Grade

Student 1
Last Name:
First Name:
Grade:
School:
Special Circumstance:

Student 2
Last Name:
First Name:
Grade:
School:
Special Circumstance:

Student 3
Last Name:
First Name:
Grade:
School:
Special Circumstance:

Student 4
Last Name:
First Name:
Grade:
School:
Special Circumstance:

Student 5
Last Name:
First Name:
Grade:
School:
Special Circumstance:

Student 6
Last Name:
First Name:
Grade:
School:
Special Circumstance:

PART D. TOTAL MONTHLY HOUSEHOLD INCOME– Report income for all members of household excluding Foster Children. If the amount is zero, enter "0"

If you have reported a case number above (Section B), you do not need to fill in this section. Simply submit the form by clicking the "submit" button below.

TYPE OF INCOME

1: Gross Monthly Earnings: Wages, Salary, Commissions

2: Monthly Welfare Payments, Child Support, Alimony

3: Monthly Payments from Pensions, Retirement, Social Security

4: Monthly Dividends or Interest on Savings

5: Monthly Worker's Compensation, Unemployment, Strike Benefits

6: Other Monthly Income (SSI, VA, Disability, Farm, other)

PART E. SIGNATURE - I certify (promise) that all information on this report is true and that all income is reported. I understand that the school will get federal/state funds based on the information I give. I understand that school officials may verify (check) the information.